35 years old female with fever and ulcers over body
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
35 year old female, farmer by occupation resident of aakaram came to the general medicine OPD with chief complaints of fever and ulcers since 6 days
HOPI:
The patient was apparently asymptomatic until 6 days back she then developed low grade fever sudden in onset , continuous in nature relived on medication h/0 of malaise not associated with chills,rigors,sweating, dizziness, fatigue and body pains, nausea, vomiting
Second day after onset of fever she went to her paddy farm for work in the early morning and injured her left toe while spraying fertilizer . From third day she noticed progressive painful lesions appearing on both lower limbs and upper limbs chest and neck . No loss of sensation, itching, joint pains.
Difficulty in swallowing and burning sensation in the mouth post consumption of food due to small ulcers in the mouth and not associated with any blood discharge from the mouth.
No complaints of headache, burning micturition, giddiness, chest pain, shortness of breath, palpitations, cough ,insomnia, loose stools, loss of appetite.
History of usage of semecarpus anacardium for one day. Following which she went a local practitioner and was prescribed an tablet containing deflazocort 6mg for five days itraconazole ,tofloxacin, orividazole, clobetasol propionate, and megaheal ointment for five days.
PAST HISTORY:
NO h/o hypertension, diabetes,asthma, epilepsy, tuberculosis
No known allergy
TREATMENT HISTORY : History of psoriasis vulgaris from 2 years for which she used tab methotrexate 7.5mg BD for one month and capsule itraconazole.
PERSONAL HISTORY:
Appetite: decreased
Diet:mixed
Sleep: adequate
Bowel and bladder are regular
Patient denies of any addictions
Daily activities:
wakes up at 5 am does household chores till 9am and have food for Breakfast and goes to farm and comes back by evening 5pm, cooks food, have dinner and go to bed by 9pm.
FAMILY HISTORY:
no history of similar complaints within the family
General examination
Pallor: absent
Icterus:absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema: absent
SKIN :hyperpigmented macules and ulceration All over the body
Local rise in temperature present
On 3/2/2023
Vitals:
Temp: afebrile
BP : 110/70
Heart rate : 110 bpm
Resp Rate 16cycles/min
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l air entry, no added sounds
CVS EXAMINATION:
I: No precordial bulge. Apical impulse
visible
P: Apical impulse, No palpebral pulsation.
A: S1 S2, No murmur
ABDOMINAL EXAMINATION:
Abdomen is soft and non tender
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard
CNS
No focal neurological deficits
ORAL CAVITY EXAMINATION:
Few whithish plaques noted over the oral mucosa
NOSE EXAMINATION:
Mild anterior DNS to left
Investigations
Fever chart
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